YECENAKEUEYG.hwp

Size: px

Start display at page:

Download "YECENAKEUEYG.hwp"

태은 승
5 years ago
Views:

1 대한물리의학회지제6권제2 호, 2011년 5월 Vol.6, No.2, May p.189~197 1) 체간근력강화운동에의한경직성양하지뇌성마비아동의대단위운동및균형능력변화 : 단일그룹반복측정연구 이은정 김종순 울산광역시장애인종합복지관, 1 부산가톨릭대학교보건과학대학물리치료학과 1 The Changes of Gross Motor Function and Balance Ability in Children with Spastic Diplegic Cerebral Palsy by Trunk Muscle Strengthening Exercise : Single Group Repeated Measure Study Eun-Jung Lee, PT, MS, Jong-Soon Kim, PT, PhD 1 Ulsan Community Rehabilitation Center 1 Department of Physical Therapy, College of Health Sciences, Catholic University of Pusan <Abstract> Purpose : Trunk muscle weakness in the children with cerebral palsy can lead to postural and alignment problems, breathing difficulties, and so on. Therefore, children with cerebral palsy can benefit from exercises that strengthen the muscles in their trunks. The purpose of this study was to investigate the effects of trunk muscle strengthening exercise on functional gross movement and balance ability in children with spastic diplegic cerebral palsy. Methods : We used single group repeated measure design in 8 children(four males, four females; aged 6~12 years; mean 8. years) with diplegia. The functional gross motor outcome measured by using the GMFM and balance ability of all children was measured by pediatric balance scale. All participants were alternately received trunk strengthening exercise and neurodevelopment treatment for 40 minutes twice per week during 8 weeks. Results : Significant and clinical meaningful improvement in functional gross motor and balance ability were shown. Conclusion : The results indicate that trunk strengthening exercise has a positive effect on both functional gross motor and balance ability in children with spastic diaplegic cerebral palsy. 교신저자 : 김종순, ptjskim@cup.ac.kr 논문접수일 : 2011년 04월 1 일 / 수정접수일 : 2011년 04월 0 일 / 게재승인일 : 2011년 05월 08일

2 대한물리의학회지제6권제2호 Key Words : Trunk muscle strengthening exercise, Gross motor function, Balance ability Ⅰ. 서 론 뇌성마비는뇌의비진행적적응성손상으로위 치, 자세그리고움직임의따라변하는경직과과긴 장, 균형과협응장애, 근력의약화, 근활동조절의 변화, 근육의동시수축등과같은신경근의유해한 변화가발생한다(Damiano 등, 2001; Ikeda 등, 1998; Papavasiliou, 2009; Stackhouse 등, 2005). 이로인 해 2차적으로뇌성마비아동의기능적인일상생활 동작들이제한을받게된다. 따라서이러한기능적 문제들을해결하기위해물리치료영역에서는대단 위운동능력과가동성증진을위해다양한방법 등이동원되어오고있다. 대단위운동능력과가동성을증진시키기위해 물리치료영역에서사용되는방법들중비교적최 근활발한연구가이루어지고있는것은근력강화 운동이다. 과거, 근력강화운동은근골격계문제에 주로사용되는방법으로인식되었으며뇌성마비와 같은상위운동신경원손상환자들의치료에는명 백한과학적인근거가없어서사용이기피되어왔다. 즉, 상위운동신경원손상에서의주된문제는근력 의문제가아닌비정상적인근긴장도의문제이기 때문에경직이감소하면기능은자연적으로개선될 것이라고믿었다(Fosano 등, 1978). 따라서근력강 화운동필요하지않으며이러한운동이경직이나 비정상적인움직임을증가시킬것이라고생각하였 다 (Bobath, 1969). 그러나신경생리학적으로한근육의긴장도가증 가하면그근육의길항근은상반억제에의해억제 되며이후약증이일어나게된다는것이일반적인 사실이다. 이러한신경생리학적기전의임상적현상 은상위운동신경원 손상환자의말기에볼수있는 근약증및선택적후근절제술 (selective posterior rhizotomy) 을받은환자가경직은감소하였으나기 능적개선은크지않았다는연구보고로도알수 있다(Hodgkinson 등, 1997). 또한많은연구에서근 력강화운동이경직을증가시켰다는증거는나타 나지않았으며오히려근력강화운동을통해기능 적동작이개선되었다는연구들이보고되고있다 (Damiano와Abel, 1998; Dodd 등, 200; MacPhail 과 Kramer, 1995). 경직성뇌성마비에서흔히나타나는운동조절의 문제는체간근육의저긴장증과약증, 팔다리의근긴 장도증가, 자세반사의소실이나지연, 그리고기능 적행동을하는동안적절한속도로팔다리를유연 하게움직이는능력이상실되는것이다 (Styer-Acevedo, 1994). 이러한문제들중체간근육의약화는체간 안정성상실을초래하게되는데체간안정성은팔 다리의움직임에필수적인요소로서체간의안정성 은체간근육의약증을보이는양하지뇌성마비에게 는휠체어생활의유지, 앉은자세에서의놀이및 식사등기능적인손동작을쉽게하는데매우중요 한요소일뿐아니라손을통한풍부한정보의유 입이이루어지도록하는데도중요한작용을한다. 그러나본연구의연구자들이여러문헌검색엔 진을통해체간근력강화운동 (Trunk Muscle Strengthening Exercise; TSE) 에의한대단위운동의변화 및균형능력의변화를검색한결과, 많은연구들이 (Eek 등, 2008; Lee 등, 2008; Liao 등, 2007; McNee 등, 2009; Stackhouse 등, 2007; van der Linden 등, 2008) 하지근력강화에의한기능의변화를분석하 였으나체간근력강화운동에의한양하지뇌성마비 의기능변화에대한연구는거의이루어지지않고 있는실정이었다. 따라서본연구는불안정한지면 에서의체간근력강화운동에의한양하지뇌성마비 아동의균형및대단위운동의변화를장기적인관 점에서연구하고자하였다. 1. 연구대상및절차 Ⅱ. 연구방법

3 체간근력강화운동에의한경직성양하지뇌성마비아동의대단위운동및균형능력변화: 단일그룹반복측정연구 Table 1. Participants demographics No Gender Gestational age (Weeks) Age (years) Height (cm) Weight (kg) GMFCS Prior medical intervention 1 F level Ⅰ Botox 2 M level Ⅲ - M level Ⅲ - 4 M level Ⅱ Bilateral myotenotomy, Botox 5 F level Ⅲ Bilateral myotenotomy, Botox 6 M level Ⅱ Bilateral myotenotomy 7 F level Ⅲ Bilateral myotenotomy 8 F level Ⅱ Bilateral myotenotomy 1) 연구대상 본연구는보호자및본인이자발적으로연구참 여를희망한양하지뇌성마비아동중대단위운동 기능분류체계 (Gross Motor Function Classification System; GMFCS) Ⅰ Ⅲ 단계에속하는 8명을대 상으로하였다. 연구에참여한아동은남자 4 명, 여 자 4 명이었고, 평균연령 8.8±1.84 세, 평균신장 ±11.66cm, 평균체중은 27.81±7.59kg 이었다. GMFCS에따른수준은 1단계 1 명, 2단계 명, 단 계 4 명이었다(Table 1). 2) 연구절차 본연구는 8 주간, 주 2 회, 각 40 분, 총 16회 TSE 와신경발달학적치료 (Neurodevelopental Treatment; NDT) 를반복실시하여각운동이대단위운동기능 및균형능력에미치는영향을조사하였으며 TSE 효 과의유지여부를알아보기위하여 4개월후추수 관찰(follow-up) 하였다. 전반적인연구의절차는그 림 1 과같다. 2. 연구도구및측정방법 1) 체간근력강화운동 본연구에서는 TSE를위해 Swiss ball을이용하 였다. Swiss ball의크기는대상아동이앉았을때 발이바닥에닿을수있는직경 45cm의 Swiss ball 을사용하였다. 대상아동에게 TSE에대하여사전 에충분히설명하고, 연구자가시범을통해대상아 동의이해를높였다. TSE 는주로복부근, 체간신전 근, 대둔근의근력강화에주안점을두었다. 바로누운자세에서는바로누운자세에서공을 다리아래에두고엉덩이들기를실시하였다. 네발 Pre Baseline test TSE+NDT Post 2wks 1 st post-test 4month after FW test NDT only NI Post wks 2 nd post-test Post 8wks 5 th post-test TSE+NDT TSE+NDT Post 5wks rd post-test NDT only post 6wks 4 th post-test Fig. 1. Flow of study. TSE, Trunk Strengthening Exercise; NDT, Neurodevelopmental Treatment; NI, No intervention; FW, Follow up

4 대한물리의학회지제6권제2호 Table 2. Exercise protocol for trunk strengthening Position Lying back over Swiss ball Lying prone over Swiss ball Sit tall on Swiss ball Exercise Method Step 1. Lying on back with feet on a Swiss ball. Keeping the Swiss ball still, slowly lift bottom pushing through ankles and heels. Perform. sets of 10 repetitions. Step 2. Lying prone over the Swiss ball with hands on the floor. Raise one arm in front of subject to shoulder height. At the same time, raise the opposite leg. Repeat this on the other side. Perform. ~4 sets of 10 repetitions. Step. Lie face down with subject's stomach on a Swiss ball, hands on the ground out in front of subject and feet on the ground behind subject. Slowly walk subject's hands forward as subject's body peels off the ball and subject's feet rise off the ground. Keep walking subject's hands forward until subject's shins are on the ball. Perform. Hold for 5 seconds. Rest for 10 seconds. Step 4. Sit tall on a Swiss ball(hip and knee 90 flexion) and take subject's feet on the ground. Keeping back straight. Perform. Hold for 20 seconds. Rest for 20 seconds. Step 5. Sit tall on a Swiss ball(hip and knee 90 flexion) and take subject's feet on the ground. Then the therapist applies resistance to the subject in all direction. Perform. Hold position for 5 seconds. Rest for 10 seconds. Step 6. Sit tall on a Swiss ball(hip and knee 90 flexion) and take subject's feet on the ground. Slowly perform the pelvic tilt and circumduction exercise. Perform. ~4 sets of 10 repetitions. Step 7. Sit tall on a Swiss ball(hip and knee 90 flexion) and take subject's feet on the ground. Slowly raise subject's one and/or both arms overhead with back extension. Perform. ~4 sets of 10 repetitions. Time (minutes) 2 기기자세에서는공을체간아래에두고, 상호교대 로팔, 다리( 오른팔과왼발, 왼팔과오른발) 들기, 공 을체간아래에두고손짚고앞으로나가다리를 뻗고 5 초간유지하기를실시하였다. 앉은자세에서 의운동은공에앉아고관절, 슬관절을 90도로굴곡 한자세로발은바닥에닿게하고체간은바른정 렬로하여 20 초유지하기, 공에앉아연구자의저항 에대응하여전, 후, 좌, 우각방향 5초씩안정성 유지하기, 공에앉아균형을잡으면서골반경사( 전- 후, 좌- 우) 운동과회선운동하기, 공에앉아체간을 신전하면서한팔씩들기와양팔같이들기를실시 하였다 (Table 2). 2) 기능의평가 TSE 에의한대단위운동의변화를관찰하기위 해본연구에서는대단위운동기능평가 (Gross Motor Function Measure; GMFM-88) 를사용하였다. 대단위운동기능평가는치료결과또는시간경과 에따른운동수준을기록하기위해고안된도구로 서타당도.91, 검사자간신뢰도.99의매우유용한 도구로알려져있다(Damiano 와Abel, 1996; Palisano 등, 2000). 본연구에서는대상자들이대단위운동 기능분류체계상 Ⅰ~ Ⅲ단계에해당되어눕고구르 기(lying and rolling; dimention A) 와앉기(sitting; dimention B) 를제외한네발기기와무릎서기(crawling and kneeling; dimension C), 서기(standing; dimension D), 걷기, 달리기, 도약하기(walking, running and jumping; dimension E) 의 가지영역을사용하였다. 본연구에서는균형능력의변화를분석하기위 하여아동균형척도 (Pediatric Balance Scale; PBS) 를

5 체간근력강화운동에의한경직성양하지뇌성마비아동의대단위운동및균형능력변화: 단일그룹반복측정연구 Table. Changes of the GMFM and the balance ability during the study period Period D-C X 2 D-D ʃ X 2 D-E ɛ X 2 BA λ X 2 Pre 90.47± ± ± ± wks 92.26± ± ± ±10.44 wks 92.85± ± ± ± wks 94.9± * 77.0± * 55.0± * 42.06±9.48 6wks 94.91± ± ± ±9.45 8wks 95.5± ± ± ±8.88 FW 94.1± ± ± ±9.92 Values are expressed as mean±sd. ; Dimension C(crawling and kneeling) ʃ; Dimension D(standing) ɛ; Dimension E(walking, running and jumping) λ; Balance ability *; p< * 사용하였다. 아동균형척도는뇌병변질환과발달장 애로인한경도또는중등도의운동장애를가진학 령기하동에게적용할수있는도구로서측정자내 신뢰도.99, 측정자간신뢰도.99를보이는매우신 뢰도가높은평가도구로알려져있다 (Franjoine, 200).. 통계처리 연구과정에서수집된자료는부호화한후자료 처리는유의수준 α를 0.05로하여통계패키지 PASW statics for Windows(ver. 18.0) 를이용하여 분석하였다. 먼저대상아동들의일반적특성은평 균± 표준편차로산출하였으며 TSE와NDT의반복적 용에따른대단위운동기능및균형능력변화는 프리드만검정(Friedman test) 로분석하였으며각시 기별변화를비교하기위해 Wilcoxon 부호순위검 정(Wilcoxon singed rank test) 을실시하였다. Ⅲ. 연구결과 1. 대단위운동기능의변화 대단위운동기능의경우네발기기와무릎서기 (p<.05), 서기(p<.00) 그리고걷기, 달리기, 도약하기 (p<.00) 에서모두유의한변화를보였다(Table ). 이러한변화의각시기별차이를살펴보면 TSE를 적용한후에는대단위운동기능들이호전되는경 향을보였으나 TSE를소거하는경우에는유의한변 화를보이지않았다. TSE를소거한 4개월후추수 관찰결과를보면네발기기와무릎서기, 서기, 그리 고걷기, 달리기, 도약하기는평균값에서는약간의 감소소견을보였으나통계적인별다른변화를보 Table 4. Comparison of the GMFM and the balance ability between the each period Contrast period D-C D-D D-E BA p p p p Pre vs. 2wks(TSE+NDT) wks vs. wks(ndt only) wks vs. 5wks(TSE+NDT) wks vs. 6wks(NDT only) wks vs. 8wks(TSE+NDT) wks vs. Follow-up(NI)

6 대한물리의학회지제6권제2호 이지않았다 (Table 4). 2. 균형능력의변화 균형능력은유의한변화를보였다 (Table, p=.00). 균형능력의각시기별차이의검정은 Table 4와같 다. TSE를적용한후에는균형능력이호전되는경 향을보였으나 TSE를소거하는경우에는균형능력은 유의한변화를보이지않았다 거한 (p=.08~.27). TSE를소 4개월후추수관찰결과를보면균형능력은 8 주후검사에비해유의한차이를보였다 (p=.01). Ⅳ. 고 찰 뇌성마비아동의주된문제는근약화로서 (Wiley 와, Damiano, 1998) 근약화는대단위운동이나보 행과같은기능적움직임의문제를유발하는데 (Fetters, 1991) 근력이클수록기능수준이높다 (Ross와 Engsberg, 2007). 따라서뇌성마비아동의 주된치료목표인기능개선을위해, 최근근력강화 운동을많이이용하고있다. 뇌성마비아동의문제 를연구한많은연구(Elder 등, 200; Rose와McGill, 2005; Wiley와Damiano, 1998) 에서특히다리의약 증을보고하고있다. 그러나뇌성마비아동의경우 팔다리근육의약증뿐아니라체간근육의약증도 나타난다(Burtner 등 1998). 뇌성마비아동은체간근 육의약증으로인해균형있는앉기의어려움을흔 히보인다(Hulme 등, 198; Park 등, 2001). 앉기는 아동이중력을이기고몸을바로세운자세 (upright posture) 를취하도록할뿐아니라팔의기능적움 직임에매우중요한단계로서바른앉기의결여는 휠체어나의자생활에서손의사용을제한하는것 으로이어져(Redstone 과West, 2004) 손을통한풍 부한감각입력의차단과학습의어려움을초래하며 독립적인일상생활에문제를야기한다. 또한체간근 육의약화는균형유지를어렵게하여보행이나몸 을바로세운자세에서의동작에문제를야기한다. 따라서뇌성마비아동이인격체로서품위를유지하 며사회구성원으로서독립적인생활을할수있도 록하는데목적을두는물리치료영역에서약화된 체간근육을효과적으로강화시키는것은매우중요 하다고할수있다. 본연구의결과스위스볼을이용한 하는경우가 TSE를적용 TSE를소거한경우에비해모든시점 에서유의하게대단위운동의개선이이루어짐을 알수있었다. 그리고 4개월후의추수관찰결과약 간의감소소견을보였으나 TSE를소거한 4개월 후의결과가사전평가에비해 GMFM 의변화가 % 높게나타나근력강화운동을 4개월간실 시하지않았음을고려하면비교적대단위운동의 유지효과도있는것으로사료된다. 뇌성마비아동 은길항근의동원은증가되어있고체간근육의활 동은감소되어있는데(Burtner 등, 1998) 체간과골 반의안정성문제로뇌성마비아동은머리의안정 성이결여되고이로인해움직임의폭(amplitude) 은 증가된다(Coluccini 등, 2007; Redstone 과West, 2004). 따라서본연구의결과에서보인대단위동작과 균형의개선은체간근력강화의효과로생각해볼 수있을것이다. 일반적으로스위스볼은움직임의개선을위한 저항운동에사용되며(Lehman 등, 2006) 선행연 구들(Behm 등, 2005; Lehman 등, 2006; Marshall과 Murphy, 2005, 2006) 에서스위스볼을이용한불 안정한지면의운동이안정한지면에서의운동보 다체간근육의근력강화에효과적이라고보고되었 다. 또한스위스볼과유사한불안정한지면을제 공하여체간근육의많은동원을유발하는승마치료 (hippotherapy) 연구들(Snider 등, 2007; Sterba 등, 2002; Sterba, 2007) 에서도대단위운동의개선을보 고하고있다. 따라서본연구에서와같이스위스볼 을이용한불안정한지면에서의운동이보다많은 체간근육의동원을유도한결과체간의동시수축 (co-contraction) 과관절의안정성을개선하고효과적 인체간근력강화향상이이루어져대단위운동의 개선이이루어진것으로사료된다. 본연구에서균형능력의경우 TSE를적용하는 경우가이러한운동을소거한경우에비해모든시 점에서유의하게균형능력의개선소견을보였다. 그러나 4개월후의추수관찰결과통계적으로의미 있는감소소견을보였으나근력강화운동을소거

7 체간근력강화운동에의한경직성양하지뇌성마비아동의대단위운동및균형능력변화: 단일그룹반복측정연구 한 4개월후의결과가사전평가에비해 14.69% 높 게나타나 TSE를 4개월간실시하지않았음을고려 하면비교적균형능력의유지효과도있는것으로 사료된다. 비정상적인움직임을보이는아동의주된문제들 중하나는부적절한감각정보인데 (Harris, 1971) 뇌성마비아동의체간안정성은특히체성감각 (somatosensory) 을사용할수없는상황에서정상 아동보다저하된다(Liao 등, 1997). 특히, 고유수용 성감각은신체의인식, 대단위운동과섬세한운 동, 운동계획, 움직임의조절, 자세안정성, 그리고 감정적안정감에영향을주어신체의다양한움직 임과협응, 움직임에대한자신감의기본이된다. 관절과근육으로부터유입되는고유수용성감각은 촉각및전정계로부터의감각과통합되어아동이 다양한활동으로움직일때머리로부터의감각과 신체의자세감각이동시에뇌로전달되도록하며 이들감각을효과적으로자극하는방법으로불안정 한지면에서의운동이권장되고있다. 이러한운동 은신경근의요구를증가시켜관절의고유수용성 감각과근육의반응시간(reaction time) 을개선시키 고근육활동을크게만든다(Ashton-Miller 등, 2001; Lehman 등, 2006; Naughton 등, 2005; Sheth 등, 1997). 따라서본연구에서보인균형능력의개선은 스위스볼의지속적인불안정이전정계, 체성감각 그리고시각계를자극하여신체의정렬과무게중 심을지각하는능력을증가시킨결과로사료된다 (Shumway-Cook 과 Woollacott, 2001). 이러한연구 결과는스위스볼에서의운동의체간의균형을효 과적으로개선한다고보고한Cosio-Lima 등(200) 의 연구그리고Sekendiz 등(2010) 의연구와같은결과 로서스위스볼과같은불안정한지면에서의운동은 효과적으로감각을자극하고체중의이동을조장하 여자세반응과균형반응을효과적으로유도하여 동적안정성을촉진할수있을것으로사료된다. 본연구는경직성양하지뇌성마비아동을대상 으로체간근력강화운동의효과를대단위운동기 능과균형능력의변화를통해검증하고자하였으 나다수의경직성양하지뇌성마비아동을대상으 로연구를수행하기어려운임상연구의한계로인 해효율적인연구를위해대조군설정을하지않는 단일그룹반복측정연구를진행하였다. 또한경직 성양하지뇌성마비아동에적용한체간근력강화 운동의효과에대한선행연구의부족으로연구에 참여한아동들에게체간근력강화운동만을적용할 수없는연구윤리적측면을고려하여일반적으로 경직성양하지뇌성마비아동에게임상에서적용하 는신경발달학적치료를완전히배제할수없었던 연구의제한점이존재한다. 따라서본연구의결과 를일반화하기위해서는보다많은피검자를대상 으로하고통제된연구를통한다각적분석연구가 필요할것으로사료된다. Ⅴ. 결 론 본연구의결과스위스볼을이용한체간근력강 화운동은경직성양하지뇌성마비아동의대단위 운동과균형능력을의미있게개선시키는것으로 나타났다. 따라서본연구에서와같이스위스볼을 이용한체간근력강화운동방법뿐아니라다양한 운동도구를이용한체간근력강화운동프로그램의 개발과연구가필요하다고여겨진다. 또한뇌성마비 아동의특성에맞는스위스볼을이용한체간근력 강화운동의운동강도, 빈도, 기간등의연구도필 요할것으로사료된다. 참고문헌 Ashton-Miller JA, Wojtys EM, Huston LJ et al. Can proprioception really be improved by exercises? Knee Surg Sports Traumatol Arthrosc. 2001;9(): Behm DG, Leonard AM, Young WB et al. Trunk muscle electromyographic activity with unstable and unilateral exercises. J Strength Cond Res. 2005;19(1): Bobath B. The treatment of neuromuscular disorders by improving patterns of co-ordination. Physiotherapy. 1969;55(1): Burtner PA, Qualls C, Woollacott MH. Muscle

8 대한물리의학회지제6권제2호 activation characteristics of stance balance control in children with spastic cerebral palsy. Gait Posture. 1998;8(): Coluccini M, Maini ES, Martelloni C et al. Kinematic characterization of functional reach to grasp in normal and in motor disabled children. Gait Posture. 2007;25(4): Cosio-Lima LM, Reynolds KL, Winter C et al. Effects of physioball and conventional floor exercises on early phase adaptations in back and abdominal core stability and balance in women. J Strength Cond Res. 200;17(4): Damiano DL, Abel MF. Relation of gait analysis to gross motor function in cerebral palsy. Dev Med Child Neurol. 1996;8(5): Damiano DL, Abel MF. Functional outcomes of strength training in spastic cerebral palsy. Arch Phys Med Rehabil. 1998;79(2): Damiano DL, Quinlivan J, Owen BF et al. Spasticity versus strength in cerebral palsy: relationships among involuntary resistance, voluntary torque, and motor function. Eur J Neurol. 2001;8(Suppl 5):40-9. Dodd KJ, Taylor NF, Graham HK. A randomized clinical trial of strength training in young people with cerebral palsy. Dev Med Child Neurol. 200;45(10): Eek MN, Tranberg R, Zügner R et al. Muscle strength training to improve gait function in children with cerebral palsy. Dev Med Child Neurol. 2008;50 (10): Elder GC, Kirk J, Stewart G et al. Contributing factors to muscle weakness in children with cerebral palsy. Dev Med Child Neurol. 200;45(8): Fetters L. Measurement and treatment in cerebral palsy: an argument for a new approach. Phys Ther. 1991;71(): Fosano VA, Broggi G, Barolat-Romana G et al. Surgical treatment of spasticity in cerebral palsy. Childs Brain. 1978;4(5): Franjoine MR, Gunther JS, Taylor MJ. Pediatric balance scale: a modified version of the berg balance scale for the school-age child with mild to moderate motor impairment. Pediatr Phys Ther. 200;15(2): Harris FA. Inapproprioception: a possible sensory basis for athetoid movements. Phys Ther. 1971;51 (7): Hodgkinson I, Bérard C, Jindrich ML et al. Selective dorsal rhizotomy in children with cerebral palsy. Results in 18 cases at one year postoperatively. Stereotact Funct Neurosurg. 1997;69(1-4 Pt 2): Hulme JB, Poor R, Schulein M et al. Perceived behavioral changes observed with adaptive seating devices and training programs for multihandicapped, developmentally disabled individuals. Phys Ther. 198;6(2): Ikeda AJ, Abel MF, Granata KP et al. Quantification of cocontraction in spastic cerebral palsy. Electromyogr Clin Neurophysiol. 1998;8(8): Lee JH, Sung IY, Yoo JY. Therapeutic effects of strengthening exercise on gait function of cerebral palsy. Disabil Rehabil. 2008;0(19): Lehman GJ, MacMillan B, MacIntyre I et al. Shoulder muscle EMG activity during push up variations on and off a Swiss ball. Dyn Med. 2006;5:7. Liao HF, Jeng SF, Lai JS et al. The relation between standing balance and walking function in children with spastic diplegic cerebral palsy. Dev Med Child Neurol. 1997;9(2): Liao HF, Liu YC, Liu WY et al. Effectiveness of loaded sit-to-stand resistance exercise for children with mild spastic diplegia: a randomized clinical trial. Arch Phys Med Rehabil. 2007;88(1):25-1. MacPhail HEA, Kramer JF. Effect of isokinetic strength training on functional ability and walking efficiency in adolescents with cerebral palsy. Dev

9 체간근력강화운동에의한경직성양하지뇌성마비아동의대단위운동및균형능력변화: 단일그룹반복측정연구 Med Child Neurol. 1995;7(9): Marshall PW, Murphy BA. Core stability exercises on and off a Swiss ball. Arch Phys Med Rehabil. 2005;86(2): Marshall P, Murphy B. Changes in muscle activity and perceived exertion during exercises performed on a swiss ball. Appl Physiol Nutr Metab. 2006;1(4):76-8. McNee AE, Gough M, Morrissey MC et al. Increases in muscle volume after plantarflexor strength training in children with spastic cerebral palsy. Dev Med Child Neurol. 2009;51(6): Naughton K, Adams L, Maher H. Upper-body wobbleboard training effects on the post-dislocation shoulder. Phys Ther Sport 2005;6(1):1-7. Palisano RJ, Hanna SE, Rosenbaum PL et al. Validation of a model of gross motor function for children with cerebral palsy. Phys Ther. 2000;80(10): Papavasiliou AS. Management of motor problems in cerebral palsy: A critical update for the clinician. Eur J Paediatr Neurol. 2009;1(5): Park ES, Park CI, Lee HJ et al. The effect of electrical stimulation on the trunk control in young children with spastic diplegic cerebral palsy. J Korean Med Sci. 2001;16(): Redstone F, West JF. The importance of postural control for feeding. Pediatr Nurs. 2004;0(2): Rose J, McGill KC. Neuromuscular activation and motor-unit firing characteristics in cerebral palsy. Dev Med Child Neurol. 2005;47(5):29-6. Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007;88(9): Sekendiz B, Cuğ M, Korkusuz F. Effects of Swissball core strength training on strength, endurance, flexibility, and balance in sedentary women. J Strength Cond Res. 2010;24(11): Sheth P, Yu B, Laskowski ER et al. Ankle disk training influences reaction times of selected muscles in a simulated ankle sprain. Am J Sports Med. 1997;25(4):58-4. Shumway-Cook A, Woollacott M.. Motor control theory and practical applications. 2nd ed. Baltimore. Lippincott Williams and Wilkins Snider L, Korner-Bitensky N, Kammann C et al. Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness? Phys Occup Ther Pediatr. 2007;27(2):5-2. Stackhouse SK, Binder-Macleod SA, Lee SC. Voluntary muscle activation, contractile properties, and fatigability in children with and without cerebral palsy. Muscle Nerve. 2005;1(5): Stackhouse SK, Binder-Macleod SA, Stackhouse CA et al. Neuromuscular electrical stimulation versus volitional isometric strength training in children with spastic diplegic cerebral palsy: a preliminary study. Neurorehabil Neural Repair. 2007;21(6): Sterba JA, Rogers BT, France AP et al. Horseback riding in children with cerebral palsy: effect on gross motor function. Dev Med Child Neurol. 2002;44(5):01-8. Sterba JA. Does horseback riding therapy or therapist-directed hippotherapy rehabilitate children with cerebral palsy? Dev Med Child Neurol. 2007;49(1):68-7. Styer-Acevedo J. Physical therapy for the child with cerebral palsy. In: Techlin JS, eds, Pediatric physical therapy. 2nd ed. Philadelphia. JB Lippincott van der Linden ML, Hazlewood ME, Hillman SJ et al. Functional electrical stimulation to the dorsiflexors and quadriceps in children with cerebral palsy. Pediatr Phys Ther. 2008;20(1):2-9. Wiley ME, Damiano DL. Lower-extremity strength profiles in spastic cerebral palsy. Dev Med Child Neurol. 1998;40(2):

80%, O'Sullivan (2003), (reposition sense)..(, 2001) Arokoski (2001) 1937 williams,,,,,,. (bridging exercise).,.(stevens, 2007). (lumbar stabilization

80%, O'Sullivan (2003), (reposition sense)..(, 2001) Arokoski (2001) 1937 williams,,,,,,. (bridging exercise).,.(stevens, 2007). (lumbar stabilization 1) 스위스볼을적용한교각자세변화에따른체간의근활성도비교 The Comparison of Trunk Muscles Activity During Bridging Stabilization Exercises on Swiss Ball According to Change of Position Sun-tae Son, Min-hye Kim, Hee-jin Kim, Ji-hye